Preliminary ACAER Asthma Risk Report
SAMPLE PRACTICE Sep 2018-2020
1 Your Key Results
0.9% of active of asthma patients have had lung function testing in the audit period
5.3% of active of asthma patients have had a consultation to review their asthma (including for self-management or to review an action plan) in the audit period
9.3% of active of asthma patients have had two or more flare ups (exacerbations or oral corticosteroid scripts) in the audit period
15.3% of active asthma patients have had two or more SABA prescription authorisations in the audit period
31.1% of active of asthma patients have an eosinophil count on file.
\(\rightarrow\) 12.8% of patients with an eosinophil count have a value over 300 cells/microlitre
79.4% of active of asthma patients have a smoking status on file
2 Introduction
This report summarises the results of a primary care asthma audit of your surgery by Optimum Patient Care Australia. The audit is accredited by the Royal Australian College of General Practitioners for up to 40 Quality Improvement and Continued Professional Development points for successful completion of each audit cycle.
Purpose
The objective of this clinical audit is to optimise the quality of primary care provision to patients with moderate to severe asthma by:
- Reviewing and improving practices of documentation of the care process in patient electronic medical records (EMR).
- Aligning primary care process with the national and international best practice guidelines on asthma management and the asthma cycle of care.
How to Use This Report
This report is designed to provide a simple and clear summary of your current asthma patient management practices, focusing on meaningful indicators and achievable recommendations that are aligned with international guidelines for the management of asthma (Global Initiative for Asthma - GINA), and with the Australian National Asthma Council (NAC) recommendations as published in the Australian Asthma Handbook. Your successes have been highlighted as well as areas for improvement. The improvement and implementation plan will be discussed with you prior to a re-audit after 12 months.
For all patient breakdown tables you can filter the view using the filter box above each column. Each breakdown table can be exported in a variety of formats using the Copy, CSV, PDF, and Print buttons below each table.
Key Asthma Management Areas
The review period covers the 24 months prior to the date of each data extraction (most recent extraction date (Sep. 29, 2020) and considers:
- Asthma diagnosis
- Demographics of your asthma population
- Lung function monitoring
- Markers of asthma control and severity
- Prediction/risk of future exacerbations
- Vaccination Recommendations
- Asthma management and education, including pharmacotherapy
Feedback and recommendations will be summarised according to the below definitions:
|
Aspect of management carried out in ≥80% of patients, consistent with the Practice Incentive Program (PIP) asthma cycle of care [1], and/or the Australian Asthma Handbook (AAH)/GINA guidelines [2]. |
|
Aspect of management carried out in 50-79% of patients, indicating only partially consistent Practice Incentive Programme (PIP) asthma cycle of care [1], and/or the Australian Asthma Handbook (AAH)/GINA guidelines [2]. |
|
Aspect of management carried out in <50% of patients, indicating room for improvement in order to be compliant with the Practice Incentive Programme (PIP) asthma cycle of care [1], and/or the Australian Asthma Handbook (AAH)/GINA guidelines [2] |
Patient Reported Data
As part of this audit and with your permission, OPC sends questionnaires to your asthma patients to collect additional information about their asthma and how they manage it. If available at the time of this document going to press, patient-reported outcomes (comorbidities, smoking status, asthma consultations and asthma control) have been incorporated into this practice-level report where appropriate.
Optimum Patient Care Australia
Optimum Patient Care (OPC) has been established to support primary care management of chronic diseases in Australia and across the world. Since its conception, OPC Australia has developed its Clinical Review and Research programs in asthma and COPD, allowing GPs who join the OPC network to further:
- Reflect and add clarity to their data and patterns of care
- Identify those patients with high priority needs & improve patient care
- Compare with other GPs & national/international guidelines
- Research using a unique data source and contribute to cutting edge science
- Learn with input from world leading experts during local educational workshops
We are committed to bringing research to primary care by advocating for data generated from experience with routine medical care in electronic medical records (e.g., clinical management in primary/ secondary care databases) or national registries (e.g., birth or cancer registries). Ideally, evidence-based good clinical practice relies on a combination of clinical experience (both personal and published real-world data) and experimental (clinical) research implemented. In the UK, OPC has published over 70 papers from the Optimum Patient Care Research Database (OPCRD-UK).
We believe that clinical review and research provides an opportunity to deliver evidence-based and data-driven educational programs that make a difference to clinical practice. Our educational programs amalgamate research findings from primary care with clinical practice to provide high quality education.
We would finally like to thank your staff for their help during the review process. We would be happy to discuss the contents of this report with you.
Website: https://optimumpatientcare.org.au/
3 Identifying Patients with Active Asthma
The National Asthma Council encourages the maintenance of diagnostic records for optimum patient management. Evidence of up to date recording and provision of quality asthma care additionally aligns with PIP guidelines for quality improvement activities.
Source data and definitions used for the indicators in this flow chart:
Conditions: Patients are identified as active/inactive based on their status on file in your main practice database. The sample of patients potentially eligible for audit initially includes all patients with a diagnosis of asthma, chronic obstructive pulmonary disease (COPD), or cystic fibrosis (CF) anywhere in their patient history identified using text terms and software codes (Best Practice or Medical Director condition codes).
Medications: Additional patients prescribed two or more asthma medications listed in the Appendix in the 24 months up to the extraction date are also included in initial assessment.
Defining the patient sample: The final “Asthma Sample” is defined as patients from the above pool with an asthma diagnosis, over 12 years of age, and with at least one asthma medication prescribed in the past 24 months. Patients with asthma/COPD or asthma/CF overlap are removed for the purposes of the audit. Note that asthma questionnaires are sent to a limited subset of these asthma patients between 18 and 75 years of age based on high risk status.
Practice Breakdown
Understand and Act
Interpretation & Recommendations
| Summary | 44.4% of those potentially eligible for the audit had evidence of active asthma (1070 of 2408). 3.9% could be excluded as COPD patients or cystic fibrosis patients, leaving 51.7% (1244 of 2408) unclassified. Patients with active asthma (audit sample): 2.6% (1070 of 41753). |
| Recommendation | The Australian Asthma Handbook encourages maintenance of clear diagnostic records for optimum patient management. Evidence of record maintenance and provision of quality asthma care additionally aligns with PIP guidelines for Asthma Cycle of Care incentives. Recommend review of records of unclassified patients |
Screened Asthma Patients Breakdown
4 Asthma Control, Severity & Risk
4.1 Exacerbations & OCS
9.3% of your asthma patients had two or more acute/exacerbation incidents
4.3 Management of High Risk Patients
12.2% (131) of patients are categorised as high risk in your asthma population. Classification is determined by either of the following conditions:
- Two or more acute asthma events in the audit period, determined by explicit information and OCS prescriptions
- Three or more SABA presciption authorisations in the audit period
|
SAMPLE PRACTICE n = 131 |
OPC QI Database n = 1,363 |
|
|---|---|---|
| Current Smokers | 36 (27.5%) | 154 (11.3%) |
| Rhinitis Incidenta | 8 (6.1%) | 365 (26.8%) |
| Allergic Profileb | 40 (30.5%) | 685 (50.3%) |
| Allergy Test (IgE/skin/patch) | 5 (3.8%) | 206 (15.1%) |
| Lung Function Testing | 4 (3.1%) | 150 (11.0%) |
| Average Number of Comorbidities | 1.6 | 2.8 |
| Action Plan Created/Reviewed | 14 (10.7%) | 377 (27.7%) |
| Eosinophil Blood Testa | 70 (53.4%) | 842 (61.8%) |
| High Blood Eosinophil Profilec | 31 (23.7%) | 255 (18.7%) |
| Referred to a Respiratory Specialista | 0 (0.0%) | 46 (3.4%) |
| Asthma-Specific Referrala | 0 (0.0%) | 37 (2.7%) |
| a In the last 24 months | ||
| b Food/environmental allergy, atopic dermatitis or allergic asthma | ||
| c Eosinophils >300 cells per mm3 or >4% WBC |
Understand and Act
Interpretation & Recommendations
| Summary |
9.3% (100) of asthma patients had two or more indications of acute asthma flare-ups during the audit period (exacerbation recorded on file or a prescription for OCS). 5.5% (59) of asthma patients had 3 or more SABA prescription authorisations in the audit period. |
| Referral |
High risk 1: For patients with 2 or more exacerbations in audit period consider:
High risk 2: For patients with 3 or more SABA prescription authorisations in audit period consider:
|
Patient Breakdown
5 Demographics of Asthma Patients
The National Asthma Council (NAC) separates guidelines for asthma diagnosis and management by age group (adults and adolescents) . Patterns of comorbidities in asthma patients may affect asthma control, risk of exacerbations and responses to therapy , and may also be gender or age specific. This section summarises the proportions of your asthma patient sample that are adolescents (12-19) and adults (20+), and the common comorbidities of your patient population to highlight specific areas of potential focus for your practice.
(hover over plots for more details)
5.1 Age and Gender
Taken directly from an anonymised version of your patient details table. Age at date of data extraction is calculated using the year of birth of the patient (day and month of birth are not collected in accordance with privacy laws).
5.2 Comorbidities
All patients with a diagnosis of a common asthma comorbidity at any time. Diagnoses are identified anywhere in the patient history using text terms and software codes (Best Practice or Medical Director condition codes).
| SAMPLE PRACTICE | OPC QI Database | |
|---|---|---|
| Rhinitis | 60 (5.6%) | 1,525 (23.7%) |
| Gastroesophageal reflux disease (GERD) | 98 (9.2%) | 1,241 (19.3%) |
| Diabetes | 22 (2.1%) | 621 (9.6%) |
| Obesitya | 152 (14.2%) | 1,694 (26.3%) |
| Depression/Anxiety | 270 (25.2%) | 2,100 (32.6%) |
| Bronchiectasis | 2 (0.2%) | 53 (0.8%) |
| Ischaemic Heart Disease (IHD) | 10 (0.9%) | 226 (3.5%) |
| Osteoporosis/osteoarthritis | 19 (1.8%) | 891 (13.8%) |
| Hypertension | 91 (8.5%) | 1,372 (21.3%) |
| Allergies | 200 (18.7%) | 2,586 (40.1%) |
| Sleep Apnoea | 27 (2.5%) | 821 (12.7%) |
| Nasal Polyps | 2 (0.2%) | 75 (1.2%) |
| Epilepsy | 9 (0.8%) | 294 (4.6%) |
| Cancer in Records | 11 (1.0%) | 779 (12.1%) |
| a Diagnosis or last BMI \(\small\geq\) 30. |
Understand and Act
Interpretation and Recommendations
| Summary | 6.4% (68) of your asthma patients are children/adolescents and the rest are adults over 19 years. 50.5% (540) of patients have at least one comorbidity. The most common comorbid conditions are: Depression/Anxiety, Allergies, and Obesity. |
| Recommendation | National Guidelines for asthma management by age group can be found here: https://www.asthmahandbook.org.au/management. According to national and international guidelines for asthma, comorbidities should be identified and managed as part of asthma review consultations, particularly in patients with poor control or severe asthma at least once every 1-2 years (GINA 2019). |
Patient Breakdown
6 Smoking Status & Smoking Support
Smoking increases the risk of flare-ups and accelerated lung function decline in asthma patients . It is a potentially modifiable risk factor , therefore every asthma patient should have their smoking status recorded and smokers should be offered smoking cessation support.
Patients are categorised within your practice software as a smoker, ex-smoker, or non-smoker. Smoking status is often not recorded for everybody, and the proportion of asthma patients with any record of smoking status is shown below. Evidence of smoking cessation support is taken from two places:
- The patient clinical record: indications in clinical text of referral to stop smoking services, or of some form of smoking assessment/support provided during a patient visit.
- The patient prescriptions record: prescriptions for Champix, Chantix, Varenicline, Bupropion, Zyban, or nicotine replacement therapies.
(hover over plots for more details)
6.1 Smoking Status
79.4% (850) of asthma patients have a smoking status recorded.
6.2 Smoking Cessation Support
Of your asthma patients who are current smokers only 12.8% (29) of them have had some form of smoking cessation support in the audit period.
Understand and Act
Interpretation & Recommendations
|
79.4% (850) of your asthma patients have a smoking status on file. 21.1% (226) are smokers. |
|
12.8% (29) of smokers have had some form of smoking cessation support in the audit period. |
| Recommendation | Consider: Reviewing the smoking status for all asthma patients, and updating records as necessary. Be sure to include risk of environmental exposure to tobacco and document all findings in the patient medical records. Consider: Smoking cessation therapy for smokers. Exposure to cigarette smoke reduces the effectiveness of asthma therapy and contributes to poor asthma control. High quality reviews have shown that nicotine-replacement therapy or pharmacotherapy like Champiz improves the probability of smoking cessation by one-and-a-half to three times over no treatment[5],[6]. As part of future consultations offer smoking exposure/cessation support and/or pharmacotherapy to smokers. Guidelines from the NAC recommend that smokers are repeatedly offered support whether a patient shows interest or not, and should be prescribed pharmacotherapy as needed. |
Patient Breakdown
7 Spirometry & Lung Function Testing
Spirometry should be used to both confirm a diagnosis of asthma, and for continual monitoring of lung function and risk of worsening asthma as part of asthma review meetings.
In confirmation of an asthma diagnosis - at least one record of airflow limitation should be on file, shown by a ratio of forced expiratory volume in 1 second to forced vital capacity of less than 0.75-0.85, and a record of airflow variability recorded as a change from baseline FEV1 of around 12% or more after bronchodilator use.
Source data and definitions used to ascertain spirometry status in the EMR:
- A mention of spirometry performed during a patient visit
- An MBS re-imbursement code for asthma spirometry
- Spirometry test results in any of the observations, documentation, or laboratory results tables
(hover over plots for more details)
7.1 Overall Monitoring
The below chart examines the full record of the patient that is available to find a record of lung function testing ever.
7.2 Monitoring in Audit Period
The below chart examines the last 24 months of the patients’ records to find a record of lung function testing.
Understand and Act
Interpretation & Recommendations
|
3.3% (35) of your asthma patients have had a record that spirometry was performed at any time. 0.9% (10) of your asthma patients have had a record that spirometry was performed during the audit period. |
|
2.4% (26) of asthma patients had a test result for FEV, FVC or PEFR at any time. 0.7% (7) of asthma patients had a test result for FEV, FVC or PEFR during the audit period. |
| Recommendation | It is possible that records of spirometry are contained in visit notes (free text) that are not included in the audit. Consider: Reviewing the spirometry records for all asthma patients and updating spirometry values into your software’s standardised results tables where necessary. Consider: In accordance with NAC guidelines, include spirometry testing during the annual review to validate a diagnosis of asthma, or to assess the future risk of worsening asthma, and/or to monitor lung function decline. |
Patient Breakdown
8 Allergies
Allergies are often comorbid with asthma, and allergens can trigger asthma symptoms and exacerbations. Identification and management of allergies can help reduce the risk of worsening asthma.
Source data and definitions used to assess allergy profile of patients:
Allergy recording: Patients with allergies are identified via their clinical history using text terms and software codes (Best Practice or Medical Director condition codes) for allergic asthma, allergic rhinitis, atopic eczema, food or drink allergies and/or other environmental allergens anywhere in their record. Allergens can be recorded at any time.
Allergy testing: Patients with a record of a radioallergosorbent test (RAST), any other reference to IgE testing, a patch test, or a skin prick test anywhere in their record. Allergy testing can be recorded at any time.
(hover over plots for more details)
8.1 Allergy Testing
| SAMPLE PRACTICE | OPC QI Database | |
|---|---|---|
| IgE Test | 6 (0.6%) | 536 (8.3%) |
| RAST Test | 6 (0.6%) | 457 (7.1%) |
| Patch Test | 0 (0.0%) | 0 (0.0%) |
| Skin Prick Test | 0 (0.0%) | 62 (1.0%) |
| Total Allergy Testing | 11 (1.0%) | 696 (10.8%) |
Understand and Act
Interpretation & Recommendations
|
18.7% (200) of your asthma patients have a record of an allergy. 1% (11) of your asthma patients have been tested for allergies. 183.3% (11 / 6) of your asthma patients with an allergy have had a test to confirm an allergy diagnosis. |
| Recommendation | Consider: whether an assessment or test for allergies is appropriate for patients where an allergy is suspected, and where an allergy diagnosis may guide asthma management and treatment. Australian National guidelines on allergies recommends that physicians should consider allergy testing as part of diagnostic investigations if you suspect allergic triggers [for asthma symptoms], or to guide management. Skin prick testing is the recommended first choice allergy test of the Australasian Society of Clinical Immunology (ASCIA). Note that in patients with severe or unstable asthma, allergy testing should be carried out by a specialist to minimise risk. |
Patient Breakdown
9 Eosinophils
Patients with eosinophilic asthma can experience more frequent exacerbations or other signs of poor control, even despite treatment with high dose medication. Patients with high eosinophil counts - over 300 cells per microlitre - have been identified below for potential further review.
(hover over plots for more details)
9.1 Audit Testing Percentage
9.2 Eosinophil Profile
Understand and Act
Interpretation & Recommendations
| Summary | 31.1% (333) of your asthma patients have had an eosinophil test during the audit period. 41.1% (137) of those with an eosinophil test result had an average eosinophil count of 300 cells/microlitre blood or higher during the audit period. |
| Recommendation | The presence of high eosinophils (eosinophilia) is a common marker of type 2 inflammation in asthma patients, and is associated with more severe type 2 disease. Next steps: As part of future consultations, review markers of asthma severity, including eosinophils, order to identify patients requiring specialist review. For those whom do not have up to date records, please assess as a priority. As a part of the consultation, outcomes should be clearly, and if appropriate, numerically documented in the patient medical records. Consider: Whether high risk patients with eosinophilia may benefit from inflammation-targeted management strategies (increasing corticosteroid dose, alternative biologic treatments). |
Patient Breakdown
10 Asthma Management & Referrals
Whilst international guidelines recommend that you take every opportunity to assess a patient with asthma, a formal review of their asthma should be scheduled at least once a year, and should include spirometry, assessment of asthma control, a review of patient medication, inhaler technique, their action plan, management of comorbidities, and consideration for specialist referral.
Several indicators were examined to indicate that an asthma review may have taken place in the audit period: completion of the asthma ‘cycle of care’ (pre-2019 PIP), provision of an action plan (at any time), spirometry results (forced expiratory volume in one second FEV1, forced vital capacity FVC or peak expiratory flow rate PEFR), an asthma visit, record of an assessment of asthma control or inhaler technique, or a medication review.
These indicators were identified using text terms or software codes (Best Practice or Medical Director condition codes) found anywhere in the patient record, or if a record of a document relating to the activity was found (e.g. action plan or referral letter), or if test results (spirometry) are recorded.
10.1 Management & Referral Percentages
4.4% - Asthma Action Plan Created/Reviewed
0.3% - Medication Review
7.9% - Asthma Review Meeting (Any)
0.2% - Asthma Cycle of Care Completed
0% - Inhaler Technique Discussed
Understand and Act
Patient Breakdown
11 References
[1] Australian Department of Human Services, ‘Practice Incentives Program - Asthma Incentive’, 2019. [Online]. Available: https://www.humanservices.gov.au/organisations/health-professionals/services/medicare/practice-incentives-program/guidelines/asthma-incentive. [Accessed: 09-Apr-2019].
[2] National Asthma Council Australia, ‘Australian Asthma Handbook | Home’, Australian Asthma Handbook. [Online]. Available: http://www.asthmahandbook.org.au/. [Accessed: 08-Apr-2019].
[3] J. E. Fergeson, S. S. Patel, and R. F. Lockey, ‘Acute asthma, prognosis, and treatment’, J. Allergy Clin. Immunol., vol. 139, no. 2, pp. 438-447, Feb. 2017.
[4] T. Fraser and M. Tilyard, Compete Blood Count in Primary Care. Dunedin, New Zealand, 2008.
[5] K. Cahill, N. Lindson-Hawley, K. H. Thomas, T. R. Fanshawe, and T. Lancaster, ‘Nicotine receptor partial agonists for smoking cessation’, Cochrane Database Syst. Rev., no. 5, 2016.
[6] C. Silagy, T. Lancaster, L. F. Stead, D. Mant, and G. Fowler, ‘Nicotine replacement therapy for smoking cessation’, Cochrane Database Syst. Rev., no. 3, 2004.
12 Methods
Key Features
Rules-based development of audit indicators, aligned with international and national guidelines for diagnosis, treatment and management of asthma
Ability to scale up to audit GP practices across multiple software platforms: relationships established with practice software developers (Best Practice, Medical Director) providing support and proprietary prescription and condition code lists.
Flexible and automated redaction software system developed to protect personal data in free-text fields of electronic medical records (EMR).
Full use of both text and numeric EMR data: detailed text mining algorithms developed to identify key words, phrases and concepts with high accuracy; and to exclude inaccurate uses of similar or misleading terms; flexibility to allow synonyms, misspellings and colloquialisms; use of PIP Medicare codes to supplement data identification.
Main Rules
Asthma Meds
Smoking Meds
13 Queries
Any comments or questions for the OPCA audit team?
Fill in the below form providing as much detail as you can and we’ll get back to you within 5 working days.